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OverviewEmergency department (ED) visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.
National and state data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak.
Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.
Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.CDC will continue to update guidance related to EVALI as appropriate.For Healthcare Providers
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			OverviewPublic Health ReportingClinical and Product Sample InformationPrimary Case DefinitionsOut-of-Hospital Case DefinitionsPublic Health ReportingAs of November 26, 2019, states were asked to only report hospitalized EVALI cases to CDC. Further collection of data on nonhospitalized cases will be at the discretion of individual state, tribal, local, and territorial (STLT) health departments.
CDC stopped the collection of data on nonhospitalized cases of EVALI for the following reasons:
Patients with EVALI may have similar symptoms to flu or other respiratory illness, and it might be difficult to distinguish EVALI from other respiratory illnesses.
Case finding and reporting of nonhospitalized patients could become more difficult and burdensome given the potential for large numbers of respiratory illnesses during the emerging flu season and may be of limited value to the ongoing investigation.
Healthcare providers are advised to report cases of lung injury of unclear etiology and a history of e-cigarette, or vaping, product use within the past 90 days to the STLT health department.
STLT public health officials should promptly notify CDC about possible cases of lung injury associated with use of e-cigarette, or vaping, products via evali@cdc.gov.
STLT health departments that need data collection tools, reporting guidelines, and case investigation forms should email CDC at evali@cdc.gov.
Consider conducting case-finding activities that use existing data sources (e.g., local poison control center, coroner and medical examiner’s office, and other applicable surveillance systems including syndromic surveillance). CDC has developed two working syndromic surveillance definitions (one version with specific symptoms and a second focused on use of e-cigarette, or vaping, products). The latter has been preset within CDC’s National Syndromic Surveillance Program’s BioSense/ESSENCE platform, however the symptom-based syndrome category is only available as a free-text query. Either of these could be used for case-finding within the platform. Contact NSSP@cdc.gov for more information.
Consider asking the medical examiner or coroner’s office and other pathologists to report possible lung injury cases, especially lung injury cases without an alternative, likely diagnosis. If individuals are identified after death or at autopsy who showed signs of lung injury, medical examiners and coroners are encouraged to report such cases to their STLT health department.
For more information on how to determine case status for individuals who die outside of the hospital or prior to hospital admission (e.g., at home, in route to the hospital, or in the emergency department), see the 2019 Lung Injury Surveillance Case Definition for Out-of-Hospital Deaths [PDF – 67 KB].Top of PageClinical and Product Sample InformationCDC and FDA have worked together to coordinate analysis of e-cigarette, or vaping, products to provide insight into the nature of the chemical exposure(s) contributing to the lung injury outbreak.
**As of February 3, 2020,** CDC is no longer accepting clinical or product samples related to EVALI cases.
The extensive product testing conducted by both FDA and CDC to date has provided critical information regarding potential chemicals of concern. Testing is continuing at both CDC and FDA on samples that have already been submitted. Analysis of both e-liquid and aerosol emissions will complement each other, and together will help improve our understanding of exposures among case patients associated with the lung injury outbreak.
For guidance about clinical specimen collection and storage, see Laboratory Clinical Sample Collection and Storage Guidance for E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) [PDF 245 KB]
Healthcare professionals, public health officials, or other concerned citizens can use the Safety Reporting Portal to report when patients experience a problem with any tobacco product, such as an unexpected health or safety issue. Reports can be submitted about any tobacco product, including cigarettes, roll-your-own cigarettes, cigars, smokeless tobacco, electronic cigarettes and waterpipe tobacco. The FDA website has more information on what to include in a report.Top of PagePrimary Case Definitions**2019 Lung Injury Surveillance Primary Case Definition (CDC) – September 18, 2019**
Download a printable PDF version of 2019 Lung Injury Surveillance Primary Case Definition (CDC) – September 18, 2019 [PDF – 179 KB].**CONFIRMED CASE**Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset
**AND**
Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT
**AND**
Absence of pulmonary infection on initial work-up. *Minimum criteria* are:
A negative respiratory viral panel**AND**
A negative influenza PCR or rapid test, if local epidemiology supports influenza testing**AND**
All other clinically-indicated respiratory infectious disease testing (e.g., urine Antigen for *Streptococcus pneumoniae* and *Legionella*, sputum culture if productive cough, bronchoalveolar lavage (BAL) culture if done, blood culture, HIV-related opportunistic respiratory infections if appropriate) are negative**AND**
No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).**PROBABLE CASE**Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset
**AND**Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT
**AND**Infection identified via culture or PCR, but clinical team** believes this infection is not the sole cause of the underlying lung injury ***OR** Minimum criteria* to rule out pulmonary infection not met (testing not performed) and clinical team** believes infection is not the sole cause of the underlying lung injury
**AND**No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).**FOOTNOTES*** Using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette, e-cigarette, vaporizer, vape(s), vape pen, dab pen, or other device) or dabbing to inhale substances (e.g., nicotine, marijuana, THC, THC concentrates, CBD, synthetic cannabinoids, flavorings, or other substances).
**Clinical team caring for the patient.
**Notes:** These case definitions are meant for surveillance and not clinical diagnosis. These case definitions are subject to change and will be updated as additional information becomes available if needed.Top of PageOut-of-Hospital Case Definitions**2019 Lung Injury Surveillance Case Definition for Out-of-Hospital Deaths (CDC) – October 4, 2019**
Download a printable PDF version of 2019 Lung Injury Surveillance Case Definition for Out-of-Hospital Deaths (CDC) – October 4, 2019 [PDF – 67 KB].This case definition is**ONLY** meant to be used to determine case status for individuals who die outside of the hospital or prior to hospital admission (e.g., at home, in route to the hospital, or in the emergency department), for whom chest imaging and clinical evaluation outlined in the primary **2019 Lung Injury Surveillance Case Definition** have not been performed. This case definition is **NOT** intended to be used to classify case status for surviving individuals or for individuals who die in the hospital, for whom chest imaging and clinical evaluation were performed.
This case definition integrates pathologic findings from the microscopic review of lung tissue specimens. As medicolegal jurisdiction allows, autopsies should be considered for deaths among persons with a history of using e-cigarette, or vaping, products, who had antecedent respiratory or gastrointestinal symptoms, or are suspected of having possible lung injury associated with use of e-cigarette, or vaping, products.
This case definition incorporates results of assessment for pulmonary infections. If needed, fixed autopsy tissue specimens can be sent to the CDC’s Infectious Diseases Pathology Branch for tissue-based infectious disease testing (e.g., immunohistochemistry and molecular testing) and histopathologic review. Refer to the Infectious Diseases Pathology Branch (IDPB) General Guidelines for Specimen Submission for more information.**CONFIRMED CASE**History of e-cigarette product use, or vaping,* in the 90 days prior to death
**AND**
Pathologic evidence of acute lung injury (e.g., diffuse alveolar damage, acute fibrinous pneumonitis or bronchiolitis, or organizing pneumonia often with vacuolated or foamy macrophages and/or pneumocytes)
**AND**
Absence of pulmonary infection** (e.g. influenza*, S. pneumoniae, Legionella*, and other infectious diseases, including HIV-related infections as appropriate, as evidenced by microscopy, immunohistology, microbiology***, or molecular testing)
**AND**
No evidence of alternative plausible diagnoses for the lung injury in medical record or at autopsy**PROBABLE CASE**History of e-cigarette product use, or vaping,* in the 90 days prior to death
**AND**
Pathologic evidence of acute lung injury (i.e., diffuse alveolar damage, acute fibrinous pneumonitis or bronchiolitis, or organizing pneumonia often with vacuolated or foamy macrophages and/or pneumocytes)
**AND**
A positive result on testing for pulmonary infection** (e.g., influenza, *S.* *pneumoniae*, *Legionella*, and other infectious diseases, including HIV-related infections as appropriate, as evidenced by microscopy, immunohistology, microbiology***, or molecular testing), however medical examiner or other forensic pathologist believes infection is not the sole cause of the underlying lung injury
**AND**
No evidence of alternative plausible diagnoses for the lung injury in medical record or at autopsy**FOOTNOTES*** Using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette, e-cigarette, vaporizer, vape(s), vape pen, dab pen, or other device) to inhale substances (e.g., nicotine, marijuana, THC, THC concentrates, CBD, synthetic cannabinoids, flavorings, or other substances). This definition also includes “dabbing,” which involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol.
** Does not include positive results from postmortem microbiologic testing thought to represent normal viral or bacterial colonization of nasopharynx, or postmortem bacterial overgrowth of lung tissues or blood.
*** Recommended microbiology: Nasopharyngeal and/or lung swab testing for influenza, lung swab testing for respiratory viruses, postmortem cultures of lung tissue and blood. Interpretation of postmortem cultures may be complicated because of bacterial overgrowth resulting from tissue breakdown.  Medical examiners and other forensic pathologists should contact their local or state health department for assistance if such testing is not readily available at their agency.  Fixed autopsy tissue specimens can also be sent to the Infectious Diseases Pathology Branch at CDC for histopathologic evaluation, and infectious disease testing, including immunohistochemistry and molecular testing, as indicated. Refer to Infectious Diseases Pathology Branch (IDPB) General Guidelines for Specimen Submission for more information.Additional Resources for State and Local Health DepartmentsTop of PageIf you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636.
							
					
							Last Reviewed:  October 1, 2020						Source: 	Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion
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